360SCDHub Registration Form 360° SCD Hub Registration Age Verification(Required)This app is intended is intended for users who are 13 years or older. There will be no account created at this time, but feel free to use the app and website as a logged out user. I am 55 or older I am an adult (18 - 54 yrs old) I am a teenager (13 - 17 yrs old) I am under 13 Email(Required) Username(Required)This is how your name will appear in the appPassword(Required) Enter Password Confirm Password ID your Roles(Required) Living with Sickle Cell Medical Community General Public How are you living with Sickle Cell? I have SCD My child has SCD My family member has SCD How old is your child?Less than 2 years oldToddler - 3 yrs - 5 yrs oldChild - 6 yrs - 9 yrs oldPre-Teen - 10 yrs - 12 yrs oldTeen - 13 yrs - 17 yrs oldAdult - 18 yrs or olderWhat kind of Medical Professional are you? Physician Nurse Physician Assistant Community Health Worker School Nurse Patient Advocate Medical Resident Other What other type of Medical Professional are you?Are you a Title V Provider? Yes No I'm not sure What part of the General Community do you represent? Concerned Citizen Public Agency Educator School Nurse Non-Profit Partner Volunteer Corporate Other What other type of General Community are you?Do you live in Arizona?YesNoNo, but I visit oftenWhat state do you live in? Alabama Alaska American Samoa Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Other What other place do you live?What is your zip code?Gender at BirthMaleFemalePrefer not to answerEthnicityChoose all that apply White Hispanic/Latino Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Prefer Not to Answer Consent(Required) I agree to the Terms and Conditions and Privacy Policy.Special Message for Under 13 years oldUnfortunately, you need to be at least 13 years old to create an account on this portal. Please feel free to use the resource as a logged out user or encourage your mom or dad to sign up for access and tracking features. For now, please visit Visit our Kid's Zone pagePhoneThis field is for validation purposes and should be left unchanged.
